Coroner highlights hospital's lost opportunities in the death of four-year-old Warminster boy

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by Andy Baber, Senior reporter for Trowbridge

A coroner has said staff missed opportunities while trying to save the life of four-year-old Sean Turner at Bristol Royal Hospital for Children.

The Warminster youngster died in March 2012 from a brain haemorrhage after previously suffering a cardiac arrest – six weeks after he underwent vital corrective heart surgery there.

At the end of a two-week inquest today, Avon coroner Maria Voisin, recording a narrative verdict, said the evidence had raised concerns about more deaths in the future.

In a submission on Wednesday, Adam Korn, the barrister representing Sean’s parents Steve, 47, and Yolanda Turner, 45, had invited Ms Voisin to deliver a narrative verdict, and urged her to make a Prevention of Future Deaths report.

But the coroner felt University Hospitals Bristol NHS Found-ation Trust has done enough.

She said: “I’m aware that the trust has made lots of changes since Sean’s death and I don’t consider it necessary to make any report in this matter.

“I’m very sorry for the family's loss.”

Recording the narrative conclusion, Ms Voisin said "Sean Turner died on 15th March, 2012 from complications of the Fontan operation undertaken on 25th January, 2012.

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"Following surgery he developed excessive fluid loss from his drains; elevated pressures in the Fontan circulation; difficulties in anti coagulation; the development of a thrombus.

"The thrombus required treatment and Sean died due to an inter-cerebral haemorrhage which is a known complication of treatment with thrombolysis.

"In addition there were lost opportunities to render medical care or treatment to Sean in this post-operative period which include: management of his anti coagulation from 6th February, 2012 and not considering genes traction between 8th and 16th February, 2012."

Mr and Mrs Turner, of Cuckoos Nest Lane, claim their son’s death was not isolated and other children with heart problems have died at the hospital, including Luke Jenkins, aged seven, from Cardiff. Up to 10 families are believed to be taking legal action against the trust over treatment on Ward 32.

After the inquest the Turners released a statement. It read:

“At the conclusion of a very difficult period, which has been an ordeal for us, we would like to thank the coroner for carrying out this investigation.

“We are pleased with her decision, and reassured that more information about Sean’s treatment has emerged over the course of the inquest.

“At the time of Sean’s surgery in January 2012, Bristol claimed to be a centre of excellence with a specialist cardiac unit. Although Sean needed a high level of nursing attention, at times on Ward 32 he didn’t even receive the most basic care. There was a lack of leadership, accountability and communication.

“We saw how nurses from Ward 32 could not remember who did what, and who could not give a consistent account of Sean’s care. We learned that Sean’s cardiac surgeon Mr Parry did not undertake any formal surgical reviews on Sean until after his cardiac arrest, at which point it was too late for our son.

“We also heard how the haematologists lacked proper involvement in Sean’s care, and that, despite the coroner’s expert view that he was a high-risk patient for developing blood clots, they failed to adequately monitor him for clotting. All of this is shocking and unacceptable to us.

“A major concern for us was the trust’s apparent failure to investigate and follow up the 10 expressions of concern over staffing levels, raised over a seven-month period, which the CQC inspection in September 2012 made apparent.

“There did not seem to be a plan for Sean’s care, which was disjointed and, in our view, shambolic.

“We do not feel that Bristol was carrying out a sufficient number of Fontan procedures for its surgeons to command appropriate levels of skill, enabling them to deal with post-operative complications. Sean’s case has shown us the impact that this can have on patient safety when things go wrong.

“We are relieved there have been changes made at the unit since Sean’s death, but we remain concerned that the risks to patients at Bristol may still be very real. We have not seen enough evidence to persuade us that the lessons of Sean and Luke Jenkins’ deaths, less than a month apart, have been learnt.

“We feel there had been a lack of remorse at some levels within the trust. There is also a suspicion that the trust was prepared to take unacceptable risks with children’s care until they were caught out. Bristol had knowingly been carrying out the most complex surgery without sufficient high-dependency facilities, and without a 24-hour, integrated team.

“There were many missed opportunities to rescue Sean from his desperate situation. In our opinion, Sean was in the wrong hospital with the wrong surgeon. We now have to try and rebuild our lives without our little boy.”